Provider Demographics
NPI:1659523694
Name:TETON HEARING CENTER LLC
Entity Type:Organization
Organization Name:TETON HEARING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER/AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-A FAAA
Authorized Official - Phone:208-569-8787
Mailing Address - Street 1:P.O. BOX 692
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422
Mailing Address - Country:US
Mailing Address - Phone:208-569-8787
Mailing Address - Fax:208-354-2656
Practice Address - Street 1:50 SKI HILL RD.
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:208-569-8787
Practice Address - Fax:208-354-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA-974231H00000X, 237600000X
IDAUD1142231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125563100Medicaid
ID807694600Medicaid